Health Information Request Form - Philippines

Health Information Request Form Template for Philippines

A standardized form designed for use in the Philippines that facilitates the formal request and release of health information, ensuring compliance with the Data Privacy Act of 2012 (RA 10173) and other relevant Philippine healthcare regulations. The document serves as a legal instrument for patients or authorized representatives to request access to medical records while protecting patient privacy rights and maintaining proper documentation of the request process. It includes comprehensive sections for patient identification, specific information requested, purpose of the request, and necessary authorizations, along with provisions for special circumstances such as urgent requests or third-party access.

Your data doesn't train Genie's AI

You keep IP ownership of your information

Generate a Bespoke Document

1. Select your governing law:

2. Enter your key requirements:

3. Create your document to edit, review or download

Download a Standard Template

Get our Philippines-compliant Health Information Request Form

4.6 / 5

4.8 / 5

Alternatively: Run an advanced review of an existing
Health Information Request Form

Let ��Ƶ's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.

What is a Health Information Request Form?

The Health Information Request Form is a crucial document used in Philippine healthcare settings to manage and track requests for medical information while ensuring compliance with local regulations. This form is essential when patients, healthcare providers, or authorized third parties need to access medical records, test results, or other health-related information. It serves as a formal mechanism for documenting consent and maintaining an audit trail of health information access, as required by the Data Privacy Act of 2012 and various healthcare regulations in the Philippines. The form is designed to protect patient privacy while facilitating necessary information sharing between authorized parties, incorporating specific provisions for different types of health information and various request scenarios.

What sections should be included in a Health Information Request Form?

1. Patient Information: Basic identifying information of the patient including full name, date of birth, address, contact details, and patient ID number if applicable

2. Requestor Information: Details of the person requesting the information if different from the patient, including relationship to patient and contact information

3. Information Requested: Specific details of the medical information being requested, including date range and types of records

4. Purpose of Request: Clear statement of the reason for requesting the health information

5. Authorization Statement: Formal authorization language compliant with the Data Privacy Act

6. Release Method: Preferred method of receiving the requested information (electronic, physical copies, etc.)

7. Verification Requirements: List of required identification documents to process the request

8. Processing Timeline: Statement of expected processing time and any applicable fees

9. Signature Block: Space for dated signatures of the patient/authorized representative and witness if required

What sections are optional to include in a Health Information Request Form?

1. Urgent Request Details: Additional section for expedited processing requests, including justification for urgency

2. Third Party Authorization: Section required when information is to be released to a third party other than the patient

3. Special Categories of Data: Additional authorization sections for sensitive information like mental health records or HIV status

4. Insurance Information: Section for insurance details when request is related to insurance claims

5. Healthcare Provider Selection: Section for selecting specific healthcare providers when requesting records from multiple sources

What schedules should be included in a Health Information Request Form?

1. Schedule A - List of Required Documents: Detailed list of acceptable identification documents and supporting papers

2. Schedule B - Fee Schedule: Breakdown of applicable fees for different types of records and processing times

3. Schedule C - Privacy Notice: Detailed privacy notice explaining how the requested information will be handled

4. Appendix 1 - Terms and Conditions: Complete terms and conditions for the information request service

5. Appendix 2 - Consent Forms: Additional consent forms for special categories of medical information

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Cost

Free to use

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Insurance

Legal Services

Medical Research

Pharmaceutical

Public Health

Education (Medical Institutions)

Government Healthcare

Healthcare Technology

Medical Device Manufacturing

Relevant Teams

Medical Records

Compliance

Legal

Patient Services

Health Information Management

Quality Assurance

Data Protection

Administrative Services

Insurance Processing

Clinical Documentation

Relevant Roles

Medical Records Officer

Privacy Officer

Healthcare Administrator

Compliance Manager

Medical Secretary

Health Information Manager

Legal Compliance Officer

Patient Relations Coordinator

Clinical Documentation Specialist

Healthcare Quality Manager

Data Protection Officer

Medical Office Manager

Insurance Claims Processor

Medical Administrative Assistant

Healthcare Legal Counsel

Find the exact document you need

No matches found.

Vehicle Release Form From Police Department

An official Philippine National Police document authorizing and recording the release of an impounded vehicle to its verified owner or representative under Philippine law.

��������Ƶ

How Cambridge United Uses ��������Ƶ to Speed Up Player Signings and Slash Legal Costs

Generate a Bespoke Document

Download a Standard Template

What is a Health Information Request Form?

What sections should be included in a Health Information Request Form?

What sections are optional to include in a Health Information Request Form?

What schedules should be included in a Health Information Request Form?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

Cost

Find the exact document you need

Vehicle Release Form From Police Department

Simple Photo Consent Form

Release Of Personal Information Consent Form

Psychiatric Release Of Information Form

Medical Release Of Liability

Medical Release Information

Photo Release Authorization Form

Return To Work Medical Release Form

Consent For Release

Motor Vehicle Record Disclosure And Release Form

Information Release

Generic Waiver Form

Dental X Ray Release Form

Consent Form For Release Of Information

Caregiver Medical Release Form

Authorization For Release Of Records Form

Authorization For Disclosure

Universal Release Of Information Form

Transcript Release Authorization Form

Release Of Financial Obligation Form

Publicity Consent Form

Patient Release Form

Patient Authorization For Disclosure Of Health Information

Authorization To Release Loan Information Form

Authorization For Release Of Medical Record Information

Release Of Health Information Form

Doctor Release Form To Return To Work

Online Medical Consent Form

Employee Medical Release Form

Consent To Disclose Medical Information

Consent Form To Disclose Medical Information

Release Of Liability Form For Dental Treatment

Authorization To Release Documents

Legal Medical Consent Form

Medical Release Waiver

Counseling Release Form

Student Release Form

Promissory Note Release

Patient Disclosure Authorization Form

Medication Release Form

�ұ�Ծ���’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security:

Use Cases

Generate Legal Docs Free

��Ƶ

How Cambridge United Uses ��Ƶ to Speed Up Player Signings and Slash Legal Costs

�ұ�Ծ��’s Security Promise